MEDICARE: SPREAD YOUR WINGS DEVELOPMENTAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1629543491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPREAD YOUR WINGS DEVELOPMENTAL SERVICES

Provider Business Mailing Address
First Line	:	110 BRUSHWOOD DR
Second Line	:
City	:	FORT THOMAS
State	:	KY
Zip	:	41071-8004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 BRUSHWOOD DR
Second Line	:
City	:	FORT THOMAS
State	:	KY
Zip	:	41071-8004
Country	:	US
Telephone Number	:	859-777-4328
Fax Number	:

Authorized Official
Title or Position	:	DEVELOPMENTAL INTERVENTIONIST
Name	:	MICHELE SNELLGROVE
Credential	:
Telephone Number	:	859-777-4328

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	11/28/2023

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